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What does the course of a surgery look like?

In my last Instagram post, I have asked what medical topics would be of interest to you. This is one of the questions I have received in response.

The question is particularly interesting because many people do not know how exactly the surgical procedure works.

Let’s start from the beginning: The whole procedure usually starts with a long-term disease. Up to that point, a number of visits to a doctor have been made and conservative treatment has been attempted. By conservative we mean taking medicine, undergoing physiotherapy, losing weight, … (roughly anything that does not involve surgical procedure).

At some point, the medical problems prevail and a decision has to be made to attempt treatment other than taking medicine.

When a patient has made the decision to undergo surgery, it is often heavily influenced by Google and other Internet sources. In that case, a doctor can only advise the patient to seek adequate therapy or point him/her towards an experienced surgeon.

Let us take tonsil surgery as an example. During the progression of the disease, the patient has been complaining for several months or years about recurring pharyngitis or tonsillitis. These inflammations are usually paired with strong malaise. A doctor who is generally unreluctant to perform surgeries would recommend a tonsillectomy in this situation. Tonsillectomy is a good example because it is a rather small surgery. It still requires general anaesthesia though and a patient will normally spend several days at the hospital after the surgery.

The first step is an initial briefing by the doctor. This preliminary talk can take place directly at the ENT doctor’s practice provided he or she performs the surgery. Alternatively, the patient will be asked to come to the hospital. The patient is briefed by the surgeon, who talks him or her through the surgical procedure and points out any connected risks.

The second briefing does not involve the surgeon but is held by the anaesthetist. The general anaesthesia procedure will be explained and the anaesthetist asks the patient about his body weight, height and any known drug intolerances. The briefing is usually very short. In both briefings, there should also be ample time for questions by the patient. After both briefings have finished it is time for the next phase – the hospital stay for the surgery.

Nowadays it is common for most surgical interventions that the patient is asked to check in at the hospital on the day of the surgery. The patient is expected to arrive at 7 am and is provided with surgical linen and a bed. After a waiting period, he or she will be called to the operating theatre.

When the patient is ready, he/she receives premedication. Premedication is primarily used for anxious patients and has calming as well as relaxing effects. Usual substances include Benzodiazepines, Neuroleptics, Opioids or Antihistamines. It is important to note that premedication will not be used in every case though. In some instances, the time between preparations and moving the patient to the operating theatre can be drawn out by timetable changes through emergency operations or short operations taking longer than expected.

Nursing staff will transfer the patient to the operating area in his/her bed and will then be moved to a surgical table. At this point, the first contact with the surgical nursing staff will be established.

Once the patient has made it to the operating theatre he/she will be met by the anaesthetist. Good anaesthetists will display a calm demeanour and reassure the patient that everything will be alright. The anaesthesia will begin promptly but is carried out in different phases.

What staff will be present in the operating room?

Surgical nurses: one person at the table (sterile), one person (unsterile) in the theatre to assist in fetching missing equipment during the surgery.
Operating surgeon: often this will be a senior physician or a medical specialist accompanied by an assistant doctor.
Depending on the type of surgery more doctors or nurses may be involved Anaesthetist plus optional anaesthetic nurses.
In teaching hospitals: medical students observing the surgery. Once the anaesthesia has been completed the incision will be carried out right away.

Moving back from the general procedure to the tonsillectomy; The surgeon takes his instruments and proceeds to make the incision. In the case of the tonsillectomy, he starts off by holding the tonsils with tweezers and then scoops them out of their „cove“ with the sharp curette. Whenever an incision has to be made there is a risk of bleeding. If bleeding occurs, it has to be stopped. To stop the bleeding a tweezer-like instrument is used. High-frequency alternating current (electro – caustic) is flowing through the instrument. This creates heat, which then „chars“ the opening of the vessel and thereby closes it.

The surgery then continues for several minutes or hours. As much tissue as necessary is removed and then the incision will be closed (sewed up). Once the incision has been closed the anaesthetic recovery process is initiated. The anaesthetics drugs are reduced slowly and the patient starts to wake up. Usually, the patient is not fully conscious yet during this phase and therefore has no recollection of it.

Most of the time the surgeon already leaves the operating theatre during the anaesthetic recovery process to write the surgery report.

Lastly, the patient is either transferred to the recovery room, where the slow waking – up process is supported by painkillers, or he/she is directly transferred out of the operation area.

The nursing staff then transfers the patient back to the ward. The patient then stays in the ward for several days or weeks depending on the surgery performed. In our example of tonsillectomy, he or she will most likely be released after 2-3 days.

A check in with the doctor is required 7 – 14 days after the surgery. Wound healing progress is examined and the suture is removed.